Differences in mental health symptom severity and care engagement among transgender and gender diverse individuals: Findings from a large community health center.

Amelia M Stanton,James Scholl,Dana King,Jennifer Potter,Conall O’Cleirigh,Chris Grasso,Norik Kirakosian,Abigail W Batchelder,Kenneth H Mayer,Siyan Yi

doi:10.1371/journal.pone.0245872

Abstract

Mental health disparities among transgender and gender diverse (TGD) populations have been documented. However, few studies have assessed differences in mental health symptom severity, substance use behavior severity, and engagement in care across TGD subgroups. Using data from the electronic health record of a community health center specializing in sexual and gender minority health, we compared the (1) severity of self-reported depression, anxiety, alcohol use, and other substance use symptoms; (2) likelihood of meeting clinical thresholds for these disorders; and (3) number of behavioral health and substance use appointments attended among cisgender, transgender, and non-binary patients. Participants were 29,988 patients aged ≥18 who attended a medical appointment between 2015 and 2018. Depression symptom severity (F = 200.6, p < .001), anxiety symptom severity (F = 102.8, p < .001), alcohol use (F = 58.8, p < .001), and substance use (F = 49.6, p < .001) differed significantly by gender. Relative to cisgender and transgender individuals, non-binary individuals are at elevated risk for depression, anxiety, and substance use disorders. Gender was also associated with differences in the number of behavioral health (χ2 = 51.5, p < .001) and substance use appointments (χ2 = 39.3, p < .001) attended. Engagement in treatment among certain gender groups is poor; cisgender women and non-binary patients assigned male at birth were the least likely to have attended a behavioral health appointment, whereas transgender men and cisgender women had attended the lowest number of substance use appointments. These data demonstrate the importance of (1) assessing gender diversity and (2) addressing the barriers that prevent TGD patients from receiving affirming care.

Highlights

Transgender and gender diverse (TGD; see Table 1 for definitions) individuals experience significantly greater mental health symptom severity and increased substance use compared to their cisgender counterparts [1,2,3], but data on the prevalence of specific mental health conditions across TGD groups is limited
In data extracted from the electronic medical records of almost 30,000 patients at a community health center in the Northeast US, there were significant differences in the severity of depression, anxiety, alcohol use, and other substance use symptoms by gender category, as well as significant differences in the proportions of patients across the gender groups whose PHQ-9, GAD-7, AUDIT, and DAST scores were indicative of the associated disorders
The likelihood of meeting the threshold scores for both a mental health disorder and a substance use disorder differed by gender, as did the percentages of patients who met the threshold scores and attended behavioral health and substance use appointments, though the potential association between behavioral health appointments, clinical care priorities, and gender affirming services need to be considered when interpreting the attendance findings

Summary

Introduction

Transgender and gender diverse (TGD; see Table 1 for definitions) individuals experience significantly greater mental health symptom severity and increased substance use compared to their cisgender counterparts [1,2,3], but data on the prevalence of specific mental health conditions across TGD groups is limited. Recent research indicates that non-binary individuals have higher odds of self-reported poor health due to mental or emotional difficulties and are likely to experience more symptoms and worse mental health outcomes compared to binary transgender (i.e., transgender men and women) and cisgender individuals [8, 12,13,14,15,16] These findings can be interpreted through the lens of minority stress theory [17, 18], which proposes that health disparities result from exposure to unique forms of stress, additive to the stress experienced by the general population. These stressors interact with internal processes and result in anticipation or expectation of discrimination, rejection, or non-affirmation, potentially leading to hypervigilance toward threat and pressure to conceal one’s identity to protect from harm [21]

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Conclusion